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Certificate This is to certify that this dissertation titled

“ANALYSIS OF EFFICACY OF PONSETI METHOD IN MANAGEMENT OF

IDIOPATHIC CLUBFOOT ” is a bonefide work done by Dr.V.A.Prabhu,

Postgraduate student of Coimbatore Medical College Hospital.This dissertation

has been prepared by Dr.V.A.Prabhu under my direct guidance & supervision

to my satisfaction in partial fulfillment of the Dr.M.G.R.Tamilnadu Medical

University, regulations for the award of M.S.Degree in Orthopaedics.

Date : Unit Chief Date : Professor & Head Department of Orthopaedics Date : Dean Coimbatore Medical College Coimbatore - 641014

Declaration

I declare that this dissertation titled

“ANALYSIS OF EFFICACY OF PONSETI METHOD IN MANAGEMENT OF

IDIOPATHIC CLUBFOOT” has been prepared by me, at Coimbatore Medical

College Hospital under the guidance of Prof & HOD. Dr.S.Senthilnathan,

Coimbatore Medical College Hospital, Coimbatore, in partial fulfillment of

Dr.M.G.R.Tamilnadu Medical University, regulations for the award of M.S.Degree

in Orthopaedics.

I have not submitted this dissertation to any

other university for the award of any degree or diploma previously.

Place : Dr.V.A.Prabhu , MBBS,

Date : Post Graduate in Orthopaedics,

Coimbatore Medical College Hospital,

Coimbatore.

Acknowledgement

I am obliged to record my immense gratitude to

Dr.V.Kumaran, the Dean, Coimbatore Medical College Hospital for providing all

the facilities to conduct the study.

I express my deep sense of gratitide & heartfelt thanks to

Prof.Dr.S.Senthinathan, HOD of Orthopaedics, Coimbatore Medical College

Hospital, Coimbatore for his valuable guidance and constant encouragement in

bringing out this dissertation.

I also express my sincere thanks to Prof.S.Dhandapani

and Prof.S.Elangovan for their guidance and suggestions during this dissertation.I

sincerely thank Dr.Major.K.Kamalnathan, Dr.P.Balamurugan and all assistant

professors for helping me bringing out this dissertation.

I also thank all postgraduates, tutors, staff, plaster

technicians and other members of the Department of Orthopaedics of Coimbatore

Medical College for their help.

Lastly, my sincere thanks to all my beloved patients & their

parents, who, with their excellent cooperation became the backbone of this

dissertation.

Dr.V.A.Prabhu

M.S.Ortho Postgraduate

CONTENTS

PART I Page No

1. INTRODUCTION 1

2. REVIEW OF LITERATURE 2

3. CLUBFOOT :

1.ETIOLOGY 8

2.PATHOANATOMY 11

3.CLINICAL FEATURES 13

4.CLASSIFICATION 18

5.TREATMENT 24

4. PONSETI METHOD 29

PART II

5. AIM OF THE STUDY 52

6. MATERIALS & METHODS 53

7. OBSERVATIONS & RESULTS 56

8. DISCUSSION 59

9. CONCLUSION 63

PART I

 

Introduction

Congenital Talipes Equino Varus is a complex

developmental deformation occuring in an otherwise normal child.It is one of the

most common congenital orthopaedic anomalies first described by Hippocrates as

early as 400 BC.However it still continues to challenge the skills of Orthopaedic

surgeon as it has a notorious tendency to relapse whether it is treated

conservatively or operatively.Part of the reason that the foot relapse is surgeon’s

failure to recognize the pathoanatomy.

The goal of treatment is to attain a functional, pain-

free, plantigrade foot, with good mobility without calluses, and without the need to

wear special or modified shoes. . Many of these cases are untreated or poorly

treated, leading to neglected clubfoot. These children undergo extensive corrective

surgery, often with disturbing failures and complications. Revision surgeries are

also thus more common. Although the foot looks better after surgery,functionally

it is stiff, weak, and often painful. After adolescence, pain increases and often

becomes crippling.   

                                                   Clubfoot in an otherwise normal child can be

corrected in two months or less with the Ponseti method of serial manipulations

and plaster cast applications, with minimal or no surgery.This method is

particularly suited for developing countries,where there are few orthopaedic

surgeons in rural and remote areas. The technique is easy to learn by allied health

professionals, such as physiotherapists and orthopaedic assistants. The treatment is

economical and safe.

Review of Literature

1. Treatment of congenital club foot with Ponseti method -RA Agrawal, MS

Suresh,Rajat Agrawal,Agrawal Orthopaedic Hospital, Gorakhpur, India .

Indian J Orthop 2005;39:244-7.

The Ponseti method is a safe and effective treatment for congenital

idiopathic clubfoot and radically decreases the need for extensive

corrective surgery . Non compliance with orthotics has been widely

reported to be the main factor causing failure of the technique.

2. Comparison of serial casting and stretching technique in children with

congenital idiopathic clubfoot Evaluation of a new assessment system-

Hanneke Andriesse and Gunnar Hägglund. Acta Orthopaedica 2008; 79 (1):

53–61 53 – 1871.

The casting technique according to Ponseti seems to be the better of the

two for clubfoot correction, regarding mobility and quality of motion.

3. Results of treatment of clubfoot by Ponseti's technique in 40 cases : Pitfalls

and problems in the Indian scenario -Atul Bhaskar, Shraddha Rasa. Indian

J Orthop 2006;40:196-9.

A strict protocol and parent education can improve the outcome for all

cases with the Ponseti technique.

4. Ponseti’s vs. Kite’s method in the treatment of clubfoot-a prospective

randomised study -Akshay Tiwari & Deep Sharma & Sudhir

kapoorInternational Orthopaedics (2008) 32:409–413.

Ponseti’s method is superior to Kite’s method in achieving correction in

idiopathic clubfoot in a relatively shorter period of time when used to treat

young infant.

5. Evaluation of the utility of the Ponseti method of correction of clubfoot

deformity in a developing nation -Ankur Gupta & Saurabh Singh & Pankaj

Patel & Jyotish Patel & Manish Kumar Varshney International

Orthopaedics (2008) 32:75–79.

The Ponseti method of correcting clubfoot is especially important in

developing countries, where operative facilities are not available in the

remote areas and well- trained physicians and personnel can manage the

cases effectively with cast treatment only.

6. Conservative management of idiopathic clubfoot: Kite versus Ponseti

method - AV Sanghvi, VK Mittal Journal of Orthopaedic Surgery

2009;17(1):67-71.

The Ponseti method can achieve more rapid correction and ankle

dorsiflexion with fewer casts, without weakening the Achilles tendon

7. Treatment of congenital club foot IV Ponseti J Bone Joint Surg Am.

1992;74:448-454.

Manipulation & serial application of casts supported by limited operative

intervention , yielded satisfactory results in 90 % of our patients

8. Treatment of idiopathic clubfoot - M Cooper and FR Dietz. JBJS Am.

1995;77:1477-1489.

The cavus and adductus deformities are always easily corrected with casts

and that the varus deformity of the hindfoot and the equinus determine

whether more ex-tensive operative treatment is necessary to obtain a

plantigrade foot.

9. Effect of Cast Removal Timing in the Correction of Idiopathic

Clubfoot by the Ponseti Method -Gaston Terrazas- Lafargue, M.D., and

Jose A. Morcuende. The Iowa Orthopaedic JournalVolume 27

Removing the cast just before the new cast is applied significantly

decreases the number of casts required for correction and shortens the length

of treatment.

10. Treatment of Idiopathic clubfoot – A historical review Matthew

Dobbs, M.D.José A. Morcuende, M.D.,Ph.D.Christina A. Gurnett,

Ignacio V. Ponseti, M.D.

Further research will be needed to fully understand them pathogenesis of

clubfoot, as well as the long-term results and quality of life for the treated

foot.

11.Ponseti treatment in the management of clubfoot deformity–a continuing role

in pediatric secondary care centres –Charles , Simon ,Ann R Coll Surg Engl

2007; 89: 510–512.

Combined care between secondary and tertiary centres,where a common

treatment protocol is utilised and with appropriately trained staff, has great

benefits and is a safe a effective option in the management of paediatric

clubfoot

12.The ClassicCongenital Club Foot: The Results of Treatment- Ignacio

V. PonsetiMD, Eugene N. Smoley MD .Clin Orthop Relat Res (2009)

467:1133–1145.

Although the treatment of a mild congenital club foot may be easy, the

complete and permanent correction of a severe and rigid club foot is often

difficult. Early correction of all the components of the deformity in the

shortest possible time is necessary for the proper development of the foot,

since plaster-cast treatment prolonged for many months interferes with

growth and may cause stiffness of the joints.

13.The Classic Observations on Pathogenesis and Treatment of

Congenital Clubfoot Ignacio V.Ponseti MD Jeronimo Campos .Clin

Orthop Relat Res (2009) 467:1124–1132.

Morphological studies of 6 clubfeet (2 in a 90-mm crown to rump fetus, 2 in

a 7- month-old fetus and 2 in a 3-day-old infant)gave no clues to the

pathogenesis of this deformity.Anterior tibial tendon transfer to the third

cuneiform is a useful operation for the treatment of cases of severe,relapsing

clubfoot

14. Treatment of idiopathic clubfoot using the Ponseti method :minimum

2-year follow-up - Abdelgawad AA, Lehman WB, van Bosse HJ,

Scher DM, Sala DA. J Pediatr Orthop B. 2007;16(2):98-105..

When the Ponseti method was fully followed, including initial casting,

compliance with brace and treatment of recurrences by recasting, Achilles

tenotomy and/or anterior tibial tendon transfer, our success rate was 93%.

15.Ponseti management of clubfoot in older infants.- Bor N,Herzenberg

JE, Frick .Clin Orthop Relat Res. 2006;444:224-8.

Most pediatric orthopaedists think that successful clubfoot casting depends

ontreatment started immediately after birth. Our data suggest that older

infants withclubfoot can be treated successfully without extensive surgery

16. Treatment of idiopathic club foot using the Ponseti method Initial

experience.-Changulani M, Garg NK, Rajagopal TS, Bass A, Nayagam

SN, Sampath J, Bruce CE. J Bone Joint Surg Br. 2006; 88(10):1385-7.

Of the 96 feet which responded to initial casting, 31 (32%) had a recurrence,

16 of which were successfully treated by repeat casting and/or tenotomy

and/or transfer of the tendon of tibialis anterior. The remaining 15 required

extensive soft-tissue release. Poor compliance with the foot-abduction

orthoses (Denis Browne splint) was thought to be the main cause of failure

in these patients.

17. Initial management of congenital varus equinus clubfoot by Ponseti’s

method.- Chotel F, Parot R, Durand JM, Garnier E, Hodgkinson I,

Berard J. Rev Chir Orthop Reparatrice Appar Mot. 2002; 88(7):710-7

In 1948, Ponseti proposed reducing the deformity with successive casts.

Although cast treatment is a very old method, Ponseti's method is original

because it is based on strict rules established from anatomic evidence

18. Evaluation of the treatment of idiopathic clubfoot by using

the Ponseti method- Colburn M, Williams M. J Foot Ankle Surg.

2003;42(5):259-67.

In all recurrent cases, there was a lack of compliance with the straight-last

shoe and foot abduction bar regimen. Based on this level of initial success,

we believe that posteromedial release is no longer necessary for the majority

of cases of congenital clubfeet.

19. Factors predictive of outcome after use of the Ponseti method for the

treatment of idiopathic clubfeet.- Dobbs MB,Rudzki JR, Purcell DB,

Walton T, Porter KR, Gurnett CA. J Bone Joint Surg Am. 2004 Jan;

86-A(1):22-7.

Noncompliance and the educational level of the parents (high-school

education or less) are significant risk factors for the recurrence of clubfoot

deformity after correction with the Ponseti method. The identification of

patients who are at risk for recurrence may allow intervention to improve the

compliance of the parents with regard to the use of orthotics,and, as a result,

improve outcome.

20.Treatment of congenital clubfoot with the Ponseti method.- Eberhardt

O,Schelling K, Parsch K, Wirth T Z Orthop Ihre Grenzgeb.

2006;144(5):497-501.

With the Ponseti method the need for extensive corrective surgery is greatly

reduced. We recommend the Ponseti method as standard therapy in clubfoot

management.

21. Ponseti technique for the correction of idiopathic clubfeet presenting

up to 1 year of age. A preliminary study in children with untreated or

complex deformities.-GoksanSB,Bursali A, Bilgili F, Sivacioglu S,

Ayanoglu S . Arch Orthop Trauma Surg. 2006;126(1):15-21.

Ponseti technique is reproducible and effective in children at least up to

12months of age. It can also produce good correction in children presenting

with complex idiopathic deformities.

Clubfoot - Etiology

The true etiology of congenital clubfoot is

unknown. Most infants who have clubfoot have no identifiable genetic,

syndromal, or extrinsic cause. Extrinsic associations include teratogenic

agents (eg, sodium aminopterin), oligohydramnios, and congenital

constriction rings. Genetic associations include mendelian inheritance (eg,

diastrophic dwarfism; autosomal recessive pattern of clubfoot

inheritance).Cytogenetic abnormalities can be seen in syndromes involving

chromosomal deletion. Clubfoot often coexists with other congenital

abnormalities, such as arthrogryposis, myelomeningocele, and other

syndromes such as dystrophic dysplasia, Möbius syndrome, Larsen

syndrome, Wiedemann-Beckwith syndrome, and Pierre Robin syndrome.

Often the syndrome causes abnormal collagen, creating stiff ligaments,

capsules, and other soft tissues. It has been proposed that idiopathic CTEV

in otherwise healthy infants is the result of a multifactorial system of

inheritance.

Incidence in the general population is 1 per 1000

live births.The male-to-female ratio is 2:1. Bilateral involvement is found in

30-50% of cases. There is a 10% chance of a subsequent child being affected

if the parents already have a child with a clubfoot.Incidence in first-degree

relations is approximately 2%.Incidence in second-degree relations is

approximately 0.6%.If one monozygotic twin has a CTEV, the second twin

has only a 32% chance of having a CTEV.

Theories of the Pathogenesis

Numerous etiologies have been proposed, discarded,

rediscovered by the next generation and represented.Many theories are in

vogue because no single theory adequately explains the erratic response of

the clubfoot to treatment.

One of the first ones, described by Hippocrates, was

the mechanical theory, which postulates that clubfoot results from an

elevated intrauterine pressure during pregnancy. This was disputed because

of the absence of increased incidence in an overcrowded uterus (twinning,

large babies, hydramnios and primiparous uterus). In the past, a

neuromuscular etiology has been proposed based on the histochemical

analysis of the clubfeet. They observed an increase in Type I:II muscle fiber

ratio from 1:2 to 7:1, which suggests a possible neural basis. However,

Irani observed no such abnormality.

Several authors have advanced histological theories.

Loren et al .have shown that abnormal peroneus brevis histology correlates

with higher chances of relapse. A primary germ plasm defect was proposed

by Glimcher. An increased collagen synthesis was found by Ionasescu.

Ippolito and Ponseti have described the theory of

retraction fibrosis of the distal muscles of the calf and supporting connective

tissue.Additionally,anatomical abnormalities have been postulated to explain

the occurrence of clubfoot. Ippolito demonstrated medial angulation of the

neck and medial tilting and rotation of the body of talus. Hootnick and

associates described hypoplasia of the anterior tibial artery in patients with

clubfoot.

An alternative theory of arrested fetal development,

was proposed by Von Volkmann in 1863 and has subsequently been verified

by other authors. According to this theory, the foot is normally in

equinovarus and corrects to a pronated foot at birth. The development of the

fetal foot is arrested because of an intrinsic error or an environmental insult,

which retards the correction of the physiological position to the normal

pronated foot and results in the clubfoot seen at birth.

Studies by Palmer and Davies have shown that

clubfoot is inherited as a polygenic multifactorial trait, which implies that

genetic factors do play an important role, but the mode of inheritance is not

clear. A higher prevalence of clubfoot was found in children who were born

between December and March than at other times of the year. Edwards et al .

propose maternal hyperthermia as an adverse environmental factor in the

sensitive period of intrauterine development.The consensus theory, which

incorporates all of the above mentioned theories, probably best explains the

occurrence of clubfoot.

Pathoanatomy

The anatomy was first described by Scarpa in

1800 & subsequently verified by authors like Kite & Turco.According to

Scarpa ,clubfoot is a congenital Talocalcaneonavicular dislocation, which is

the currently accepted view.In contrast Goldstein believes that the primary

abnormality is outward rotation of talus in ankle mortise.

The ankle is in equinus, and the foot is

supinated (varus) and adducted (a normal infant foot usually can be

dorsiflexed and everted, so that the foot touches the anterior tibia).

Dorsiflexion beyond 90° is not possible.The navicular is displaced medially,

as is the cuboid. Contractures of the medial plantar soft tissues are present.

Not only is the calcaneus in a position of equinus but also the anterior aspect

is rotated medially and the posterior aspect laterally.

The heel is small and empty. The heel feels soft

to touch (akin to the feel of the cheeks). As the treatment progresses, it fills

in and develops a firmer feel (akin to the feel of the nose or of the chin).The

talar neck is easily palpable in the sinus tarsi as it is uncovered laterally.

Normally, this is covered by the navicular, and the talar body is in the

mortise. The medial malleolus is difficult to palpate and is often in contact

with the navicular. The normal navicular-malleolar interval is diminished.

The hindfoot is supinated, but the foot is often in

a position of pronation relative to the hindfoot. The first ray often drops to

create a position of cavus. The Ponseti method of closed management of

clubfeet through manipulations and casting describes the elevation of the

first metatarsal as a first step, even if it means seemingly exacerbating the

supination of the foot.The tibia often has internal torsion. This assumes

special importance in the casting management of clubfoot, where care

should be taken to rotate the feet into abduction, avoiding spurious tibial

rotation through the knee.Even following correction, the foot often remains

short and the calf thin.

Atrophy of the leg muscles, especially in the

peroneal group, is seen in clubfeet.The number of fibers in the muscles is

normal, but the fibers are smaller in size.The triceps surae, tibialis posterior,

flexor digitorum longus (FDL), and flexor hallucis longus (FHL) are

contracted.The calf is of a smaller size and remains so throughout life, even

following successful long-lasting correction of the feet.There is thickening

of the tendon sheaths of tibialis posterior and peroneal tendons.

Contractures of the posterior ankle capsule,

subtalar capsule, and talonavicular and calcaneocuboid joint capsules

commonly are seen. Contractures are seen in the calcaneofibular, talofibular,

(ankle) deltoid, long and short plantar, spring, and bifurcate ligaments.The

plantar fascial contracture contributes to the cavus,as does contracture of

fascial planes in the foot.

Clinical Features

The ankle is in equinus, and the foot is supinated

(varus) and adducted. Dorsiflexion beyond 90° is not possible.

The navicular is displaced medially, as is the cuboid.

Contractures of the medial plantar soft tissues are present. Not only is the

calcaneus in a position of equinus but also the anterior aspect is rotated

medially and the posterior aspect laterally.

The talar neck is easily palpable in the sinus tarsi as it is

uncovered laterally. Normally, this is covered by the navicular, and the talar

body is in the mortise. The medial malleolus is difficult to palpate and is

often in contact with the navicular. The normal navicular-malleolar interval

is diminished.

The hindfoot is supinated, but the foot is often in a

position of pronation relative to the hindfoot. The first ray often drops to

create a position of cavus. The Ponseti method of closed management of

clubfeet through manipulations and casting describes the elevation of the

first metatarsal as a first step, even if it means seemingly exacerbating the

supination of the foot.

The tibia often has internal torsion. This assumes special

importance in the casting management of clubfeet, where care should be

taken to rotate the feet into abduction, avoiding spurious tibial rotation

through the knee.Even following correction, the foot often remains short and

the calf thin.

Imaging Studies

Antenatal Diagnosis

With the advent of ultrasound, clubfoot can now be

diagnosed at 18-20 weeks of gestation. However, this is only 80% accurate.

If the antenatal diagnosis is made at <20 weeks, some authors have

suggested amniocentesis because of the high incidence (14.2%) of

associated genetic anomalies, such as Trisomy18, Larsen's syndrome, neural

tube defects and congenital heart defects.

Radiography

Imaging studies generally are not required to

understand the nature or the severity of the deformity. Radiographs,

however, are a useful baseline prior to and following surgical correction of

the feet, closed Achilles tenotomy, or a limited posterior release.

Radiographs show the true gain in foot (ankle) dorsiflexion and confirm the

appearance of an iatrogenic rockerbottom foot should one result.

Occasionally, radiographs are necessary to diagnose clubfeet associated with

tibial hemimelias.

Talocalcaneal parallelism is the radiographic feature of

clubfeet. Simulated weight-bearing x-rays are used for infants who have not

commenced walking. Positioning for foot x-rays is very important. The

anteroposterior (AP) view is taken with the foot in 30° of plantar flexion and

the tube at 30° from vertical. The lateral view is taken with the foot in 30° of

plantar flexion.

The talocalcaneal angle in the AP and lateral films are

measured. AP lines are drawn through the center of the long axis of the talus

(parallel to the medial border) and through the long axis of the calcaneum

(parallel to the lateral border), and they usually subtend an angle of 25-40°.

Any angle less than 20° is considered abnormal.

The AP talocalcaneal lines are almost parallel in clubfeet.

As the feet correct with casting or surgery, the calcaneus rotates externally,

and the talus reciprocally also derotates to a lesser degree to give a

convergent talocalcaneal angle.

Lateral lines are dawn through the midpoint of the head

and body of the talus and along the bottom of the calcaneum, usually 35-50°

Clubfoot ranges between 35° and negative 10°.The lateral talocalcaneal lines

are almost parallel in clubfeet. As the feet correct with casting or surgery,

the calcaneum dorsiflexes relative to the talus to give a convergent

talocalcaneal angle.These 2 angles (AP and lateral) are added to derive the

talocalcaneal index, which in a corrected foot should be more than 40°.The

AP and lateral talar lines normally pass through the center of the navicular

and the first metatarsal.

A lateral film with the foot held in maximal dorsiflexion is

the most reliable method of diagnosing an uncorrected clubfoot, since the

absence of calcaneal dorsiflexion is evidence that the calcaneus is still

locked in varus angulation under the talus.

Radiographic evaluation of Clubfoot                 

A, Anteroposterior view of right clubfoot with decrease in talocalcaneal angle and

negative talus–first metatarsal angle. B, Talocalcaneal angle on anteroposterior

view of normal left foot. C, Talocalcaneal angle of 0 degrees and negative

tibiocalcaneal angle on dorsiflexion lateral view of right clubfoot. D, Talocalcaneal

and tibiocalcaneal angles on dorsiflexion lateral view of normal left foot.

Nine angles commonly used for evaluation of clubfoot deformity. A, On

anteroposterior radiograph: A, anteroposterior calcaneal angle; B, calcaneus–

second metatarsal angle; C, anteroposterior talus–first metatarsal angle. B, On

lateral radiograph: D, lateral talocalcaneal angle; E, calcaneus–first metatarsal

angle; F, tibiocalcaneal angle; G, tibiotalar angle; H, lateral talus–first metatarsal

angle. Talocalcaneal angle is sum of A and D.

Classification

Clubfoot is classified into Congenital &

Acquired. Congenital clubfoot is further classified into Idiopathic or Non-

idiopathic types.

Congenital idiopathic clubfoot : Isolated skeletal anomaly, usually bilateral,

has a higher response to conservative treatment and a tendency for late

recurrence.

Congenital non-idiopathic clubfoot : Occur in genetic syndromes,

teratological anomalies, neurological disorders of known (eg.spina bifida) &

unknown etiology and myopathies. It is characterized by diametrically

opposite deformities in the feet (calcaneovalgus in one foot and

equinovarus in another), presence of another anomalies & failure to respond

to conservative or operative treatment.

Acquired clubfoot : Has neurogenic causes (eg.Poliomyelitis, meningitis,

sciatic nerve damage), Streeter’s dysplasia and vascular causes (Volkmann

ischemic contracture).

Positional clubfoot : Rarely the deformity is very flexible and is thought to

be due to intrauterine crowding. Correction is often achieved with one or

two castings.

Typical clubfoot : This is the classic clubfoot and is found in otherwise

normal infants. It generally corrects in five casts, and with Ponseti

management the long-term oucome is usually good or excellent.

Atypical clubfoot : This category of clubfoot is usually associated with other

problems. Start with Ponseti management. Correction usually is more

difficult.

Recurrent typical clubfoot : May occur whether the original treatment was

by Ponseti management or other methods. Relapse is much less frequent

after Ponseti management and is usually due to a premature discontinuation

of bracing. The recurrence is most often supination and equinus that is first

dynamic but may become fixed with time.

Alternatively treated typical clubfoot: Includes feet treated by surgery or

non-Ponseti casting.

Rigid or resistant atypical clubfoot : May be thin or fat. The fat feet are

much more difficult to treat. They are stiff, short, chubby, with a deep crease

in the sole of the foot and behind the ankle, and have shortening of the first

metatarsal with hyperextension of the metatarsal phalangeal joint.This

deformity occurs in the otherwise normal infant.

Scoring Systems

There are numerous evaluation systems for

grading the severity of clubfoot. All these systems use various parameters to

assess the severity and correctability of clubfoot. Harrold and Walker22

were among the first to describe a simple grading system. Although it

allowed a basic assessment of the deformity , it was not sensitive enough to

evaluate subtle improvements in outcome as a result of a particular

intervention. Dimeglio- Bensahel scoring system, Catterall-Pirani system,

the modified Hospital for Joint Diseases functional rating system25 have all

been used by workers in this field. Although a large number of evaluation

systems have been proposed, there is little agreement on a standard

reproducible method. Among these, the Dimeglio-Bensahel and the

Catterall- Pirani scoring systems appear to have a number of clinical

advantages. Both score the dynamic correctability of the deformity, rely

exclusively on clinical assessment and do not involve radiological

assessment. This removes some of the inherent errors associated with

radiographic interpretation in CTEV.

Pirani Scoring:

The Pirani scoring system, devised by Shafiq Pirani, MD,

of Vancouver, BC, consists of 6 categories, 3 each in the hindfoot and the

midfoot. The categories are curvature of the lateral border (CLB) of the foot,

medial crease (MC), uncovering of the lateral head of the talus (LHT),

posterior crease (PC), emptiness of the heel (EH), and degree of dorsiflexion

(DF). The first 3 constitute the midfoot score, and the last 3 constitute the

hindfoot score. Each category is scored as 0, 0.5, or 1. The least (best) total

score for all categories combined is 0, and the maximum (worst) score is 6.

The Pirani scoring system can be used to identify the severity of the clubfoot

and to monitor the correction.

Hindfoot deformities

• Posterior heel crease

• Empty heel

• Rigidity of equinus

Midfoot deformities

• Curvature of lateral border of foot

• Medial crease

• Lateral head of talus

Total score = [hindfoot + midfoot] deformity scores

Dimeglio - Bensahel scoring system:

The Dimeglio- Bensahel scoring system incorporated eight

components: equinus, varus, position of the talo-calcaneal-forefoot unit,

forefoot adduction, and the presence of abnormal musculature, cavus, a

medial crease and a posterior crease. Points are apportioned according to

motion, with 4 points each for equinus, varus of the heel, internal torsion and

adduction. One point each may be added for the presence of a posterior

crease, a medial crease, cavus and poor muscle condition. A total of 20

points is possible. The higher the number, the more rigid the clubfoot

Pirani Scoring for Clubfoot

Classification of Clubfoot Severity by Diméglio et al.

Parameters Measured Reducibility (degrees) Score

Equinus deviation in sagittal plane (Fig. 26-30A) 90 to 45 4

Varus deviation in frontal plane (Fig. 26-30B) 45 to 20 3

Derotation of calcaneopedal block in horizontal plane (Fig. 26-30C)

29 to 0 2

Adduction of forefoot relative to hindfoot in horizontal plane (Fig. 26-30D)

0 to −20 1

<−20 0

16

Other elements considered

Posterior crease marked  1

Mediotarsal crease marked  1

Plantar retraction or cavus  1

Poor muscle condition  1

Possible total score 20

Grade Type Frequency (%) Score Reducibility I Benign 20 1-4 >90% soft-soft, resolving

II Moderate 33 5-9 >50% soft-stiff, reducible, partially resistant

III Severe 35 10-14 >50% stiff-soft, resistant, partially reducible

IV Very severe 12 15-20 <10% stiff-stiff, resistant

 

 

 

Treatment of Clubfoot

The treatment of clubfoot can be divided into

two phases, the pre-Ponseti era and post-Ponseti era. In the pre-Ponseti era,

stress was on conservative treatment and followed by operative treatment if

the conservative treatment failed. The Ponseti technique is essentially

conservative. This does not suggest that in the post-Ponseti era all the other

modalities have been abandoned. Other methods, including surgery, are still

being followed depending upon individual preferences.

The first non-operative treatment was

proposed by Hippocrates in 400 BC when he recommended gentle

manipulation followed by splinting. Plaster casts were used to treat clubfoot

when Guerin introduced the plaster of Paris in 1836. Kite was the first to

recommend gentle manipulation and cast immobilization.At the annual

meeting of the American Academy of Orthopedic Surgeons in 2002,

Cummings stated, "There are as many techniques for manipulative treatment

of congenital clubfoot as there are authors who write about clubfoot". To

circumvent this problem, International Clubfoot Study Group, established in

2003, has approved Kite's, Ponseti's and Bensahel's techniques as the

standardized conservative regimes for the treatment of clubfoot all over

the world.

Kite’s-method

In Kite's method, the manipulation can be

started soon after birth. It was derived from the concept of three-point

pressure, such as used in the bending of a wire. The fulcrum is the

calcaneocuboid joint. The forefoot is grasped and distracted while the other

hand holds the heel. Applying counterpressure over the calcaneocuboid joint

the navicular is pushed laterally. The heel is everted as the foot is abducted.

This is followed by the application of a slipper cast, which is extended to

below the knee with the foot everted with gentle external rotation.

Afterwards, the foot is pushed into dorsiflexion to correct the equinus once

the adductus and varus are corrected. The casts are changed every week.

Following full correction, the feet are placed in a Denis Browne Bar. The

success rate varies from a high of 90% found by Kite to a low of 19% by

Fripp and Shaw. According to Ponseti, the average number of casts required

for correction by this technique is 20.4.

Kite believed that the heel varus would correct

simply by everting the calcaneus. He did not realize that the calcaneus can

evert only when it is abducted (i.e., laterally rotated) under the

talus.Abducting the foot at the midtarsal joints with the thumb pressing on

the lateral side of the foot near the calcaneocuboid joint blocks abduction of

the calcaneus and interferes with correction of the heel varus. One should

make certain the foot is abducted around the head of the talus.

French method

This technique, also known as the Functional

method, was introduced in France in the 1970s by Masse and Bensahel, but

it was not until early 1980 that results were available in english literature. It

involved daily manipulation of the child's clubfoot by the physical therapist

for 30 min. This was followed by stimulation of the muscles around the foot,

specially the peroneal muscles, to maintain the reduction achieved by the

passive manipulation and then, adhesive strapping was applied. The daily

treatments were continued for approximately two months and then reduced

to three sessions per week for an additional six months. Taping was

continued until the patient was ambulatory. After ambulation was achieved,

a nighttime splint was introduced and used for an additional two to three

years. Initially, good results were seen in 50% of the patients and in the

remaining cases, the surgery that was required was only a posterior release.

The disadvantages of this method were that it

involved daily hospital visits, depended on the manipulation skills of the

physical therapist and was costly in the long run. This method was

subsequently modified to include placement in a continuous passive motion

(CPM) machine for six to eight hours after passive manipulation by the

physical therapist and adhesive strapping of the feet. The addition of the

CPM machine resulted in fewer patients needing surgery and a less radical

procedure for those who required surgery. The success rate was reported to

be close to 68%.

Operative Treatment

The list of operative procedures is endless as no

single procedure gives a long-lasting correction. The first operative

procedure, posterior release, was described by Phelps in 1891. The PMR

procedure, which was introduced by Turco (1980), is basically a

modification of the earlier procedures elaborated by Phelps, Codvilla (1906),

Brockman (1937) and Bost (1960).

The rationale behind Turco's PMR was that the

deformity is due to the congenital subluxation of the Talocalcaneonavicular

joint, the correction of the abnormal tarsal relationship is prevented by rigid

pathologic soft tissue contractures and the correction of any single

component of the deformity is impossible while simultaneously eliminating

the others. The two prerequisites for lasting correction are that complete

correction of all components must be obtained and this correction must be

maintained while the tarsal bones remodel.

The optimal age for surgical intervention has

always been controversial. Turco recommends surgery at around one year of

age while Osterman and Merikanto recommend surgery at the earlier age of

three to six months to utilize the remodeling potential of the foot.

Danglemajor advises deferring surgery until one year of age as surgery done

earlier has a failure rate close to 65%.The average number of operations per

foot was 2.9 to achieve a full correction at skeletal maturity with earlier

surgery. In addition to finding a higher incidence of failure, Turco reported

the disadvantages of early surgery to be difficulty in the identification of the

anatomical structures and in the handling of the small cartilaginous bones

when operating on a small foot. Furthermore, when the pins are removed

from the talonavicular bones and talocalcaneal bones after a PMR, it is hard

to hold the small foot in plaster. Importantly, delaying surgery minimizes the

possibility of operating on an unrecognized neuromuscular deformity. One

major benefit of operating close to the age of walking is that it takes

advantage of the normal physiological stimulus of weight-bearing for

remodeling.

Turco's procedure was used with impunity in

the 1980s with the average failure rate of 25% being reported by Turco

himself. Failure rates, ranging from 13 to 50%, were found by Crawford et

al . and Vizekelety et al . McKay et al . and Herzenberg et al . have shown

that the presence of an internal rotation deformity of the calcaneus cannot be

adequately corrected by a PMR alone. They proposed that beyond 18

months of age PMR should be combined with posterolateral release. This

can either be done using a single incision of Cinncinnati or Carrolls two

incision technique. The disadvantage of Mckay's procedure is that it results

in overcorrection with the heel being placed in valgus in 8-20% of the feet.

The protocol followed for the management of

neglected type of feet is surgical either by open surgery as described above

or by the use of external fixators such as Iliazarov's and Joshi's External

stabilizing system (JESS) fixators. Casting is done to maintain correction

after the fixators are removed. The success rate of correction varies from 77

to 90%.As can be seen from above, surgical intervention is often followed

by complications, residual deformities or recurrence, which require further

surgery.

Ponseti Method

Ponseti had been reporting consistent results since 1950,

but it is only recently that he has been given due recognition. His technique

is based on the solid understanding of the pathoanatomy of clubfoot.

According to Ponseti, the clubfoot usually recurs until four years of age and

parents should be warned of this possibility.

Ponseti suggests two reasons for the poor results found

with Kite's technique. First, the use of the calcaneocuboid joint as the

fulcrum blocks the abduction of the calcaneus and thereby prevents eversion

of the calcaneus. Secondly, pronation of the forefoot to correct the cavus

actually worsens the cavus. A recent study by Frick highlights the

importance of correction of the supination. Based on laboratory studies,

Ponseti has shown that the calcaneus everts only when it is fully-abducted.

In Ponseti's technique, the first two casts are applied with

the forefoot supinated so as to bring it into alignment with the hind foot.The

third cast is applied with the forefoot abducted and simultaneous

counterpressure over the head of talus. In the fourth cast, the forefoot is

further abducted. Prior to the fifth cast, the degree of dorsiflexion is assessed

and if dorsiflexion is not possible beyond neutral, then a percutaneous

Achilles tenotomy is required. The tenotomy, if required, is done under local

anesthesia as an outpatient procedure. The casts before the tenotomy are

changed at weekly intervals while the cast after the tenotomy is removed at

the end of three weeks.

The average number of casts with the Ponseti

technique is only 5.4 compared to the 20 casts with Kite's technique and this

results in saving time and money for the patient.Following the removal of

the last cast, irrespective of whether a tenotomy is done or not, the patient is

placed in a modified Foot Abduction Orthosis (FAO), which is used for 23 h

a day in the initial four months and then subsequently for nighttime for three

years. According to Ponseti, a tenotomy is required in 70% of the cases. In

a study by Scher et al ., children with clubfeet who have an initial

score of ≥5.0 by the Pirani system or are rated as Grade IV

feet by the Dimeglio system are very likely to need a tenotomy.

APPEARANCE OF CASTS IN PONSETI METHOD

Clubfoot has a strong tendency to relapse until

four years of age and this is attributed to the original pathology. Relapses

decrease after age four because the pathology that causes clubfoot ceases to

exist. According to Ponseti, 50% of the relapses occurred between 10

months to five years and this was irrespective of the degree of correction that

was obtained after casting. The single most important factor that predicts

recurrence is noncompliance with the FAO and the recurrence rate could be

reduced to 10% if the patient was compliant with the FAO.

Lehman et al . have shown excellent early

results with the Ponseti technique and according to them good results

were possible if casting was begun prior to seven months of age and the

patient was compliant with the FAO. Dobbs et al . have reported that

noncompliance with the FAO and the educational level of the parents (high-

school education or less) are significant risk factors, which predict the

increased possibility of recurrence after correction with the Ponseti method.

The identification of patients who are at risk

for recurrence may allow intervention to improve the compliance of the

parents with regard to the use of the FAO and as a result, improve outcome.

Probably, the most extensive review and follow-up of the Ponseti technique

has been reported by Dobbs et al .,in their evaluation of Ponseti's patients

who were treated 25-42 years ago. They found that the corrected clubfeet

were less supple and showed no differences in terms of function and

performance compared to the normal population. Tibialis anterior tendon

transfers were required in 50% of the patients. According to Ponseti, this

should be considered part of the technique and not as a separate operative

procedure. In a recent study from Israel, Segev et al .reported excellent

results in 94% of the cases with the Ponseti technique.

Ponseti Technique

Setup : The setup for casting includes calming the child with a bottle or

breast feeding. When possible it is good to have a trained assistant.

Sometimes it is necessary for the parent to assist. The treatment setup is

important. The assistant holds the foot while the manipulator performs the

correction.

Manipulation and casting: is started as soon after birth as possible.The

infant and the family are made comfortable.The infant is allowed to feed

during the manipulation and casting processes.

The head of the talus is exactly located : This step is essential . First, the

malleoli is palpated with thumb and index finger of hand A while the toes

and metatarsals are held with hand B. Next,the thumb and index finger of

hand A is slided forward to palpate the head of the talus in front of the ankle.

Because the navicular is medially displaced and its tuberosity is almost in

contact with the medial malleolus, one can feel the prominent lateral part of

the talar head barely covered by the skin in front of the lateral malleolus.The

anterior part of the calcaneum will be felt beneath the talar head.While

moving the forefoot laterally in supination, one will be able to feel the

A

 B 

navicular move over so slightly in front of the head of the talus as the

calcaneus moves laterally under the talar head.

Manipulation: The manipulation consists of abduction of the foot beneath

the stabilized talar head. The head of the talus is located. All components of

clubfoot deformity,except for the ankle equinus, are corrected

simultaneously. To gain this correction, one must locate the head of the

talus, which is the fulcrum for correction.

The cavus is reduced: The first element of management is correction of the

cavus deformity by positioning the forefoot in proper alignment with the

hindfoot. The cavus, which is the high medial arch is due to the pronation of

the forefoot in relation to the hindfoot. The cavus is always supple in

newborns and requires only elevating the first ray of the forefoot to achieve

a normal longitudinal arch of the foot. The forefoot is supinated to the extent

that visual inspection of the plantar surface of the foot reveals a normal

appearing arch neither too high nor too flat. Alignment of the forefoot with

the hindfoot to produce a normal arch is necessary for effective abduction of

the foot to correct the adductus and varus.

Steps in cast application: Dr. Ponseti recommends the use of plaster

material because it is less expensive and more precisely molded than

fiberglass.

Preliminary manipulation: Before each cast is applied, the foot is

manipulated.The heel is not touched to allow the calcaneus to abduct with

the foot .

Applying the padding : Only a thin layer of cast padding is applied, to allow

molding of the foot. The foot is maintained in the maximum corrected

position by holding the toes with counterpressure applied against the head of

the talus while the cast is being applied.

Applying the cast : First, the cast is applied below the knee and then the

cast is extended to the upper thigh. The cast is begun with three to four turns

around the toes , and then worked proximally up to the knee. The plaster is

applied smoothly. A little tension is added to the turns of plaster above the

heel. The foot should be held by the toes and plaster wrapped over the

“holder’s” fingers to provide ample space for the toes.

Molding the cast : Forced correction with the plaster is avoided.One should

not apply constant pressure with the thumb over the head of the talus, rather

it is pressed and released repetitively to avoid pressure sores of the skin. The

plaster over the head of the talus is molded while holding the foot in the

corrected position. The arch is well molded to avoid flatfoot or rocker-

bottom deformity. The heel is well molded by countering the plaster above

the posterior tuberosity of the calcaneus. The malleoli are well molded. The

calcaneus is never touched during the manipulation or casting. Molding

should be a dynamic process; the fingers being moved constantly to avoid

excessive pressure over any single site. Molding is continued while the

plaster hardens.

The cast is extended to thigh One should use much padding at the proximal

thigh to avoid skin irritation. The plaster may be layered back and forth over

the anterior knee for strength and for avoiding a large amount of plaster in

the popliteal fossa area, which makes cast removal more difficult.

The cast is trimmed The plantar plaster is left to support the toes , and the

cast is trimmed dorsally to the metatarsal phalangeal joints, as marked on the

cast.A plaster knife is used to remove the dorsal plaster by cutting the center

of the plaster first and then the medial and lateral plaster.The dorsum of all

the toes are left free for full extension. The appearance of the first cast when

completed is noted. The foot is in equinus, and the forefoot is supinated.

Characteristics of adequate abduction It is confirmed that the foot is

sufficiently abducted to safely bring the foot into 0 to 5 degrees of

dorsiflexion before performing tenotomy.

The best sign of sufficient abduction is the ability to palpate the anterior

process of the calcaneus as it abducts out from beneath the talus.

Abduction of approximately 60 degrees in relationship to the frontal plane

of the tibia is possible.

Neutral or slight valgus of os calcis is present. This is determined by

palpating the posterior os calcis.

Clubfoot is a three-dimensional deformity Hence these deformities are

corrected together. The correction is accomplished by abducting the foot

under the head of the talus. The foot is never pronated.

The final outcome at the completion of casting, the foot appears to be over-

corrected into abduction with respect to normal foot appearance during

walking. This is not in fact an overcorrection. It is actually a full correction

of the foot into maximum normal abduction. This correction to complete,

normal, and full abduction helps prevent recurrence and does not create an

overcorrected or pronated foot.

Complications of Casting

Using careful technique, as described, complications are uncommon.

Rocker-bottom deformity is due to poor technique by dorsiflexing the foot

too early against a very tight Achilles tendon.

Crowded toes are due to tight casting over the toes.

Flat heel pad will occur if, while casting, pressure is applied to the heel

rather than molding the cast above the ankle.

Superficial sores are managed by applying a dressing and a new cast with

additional padding.

Pressure sores are due to poor technique. Common sites include the head of

the talus, over the heel, under the first metatarsal head, and popliteal and

groin regions.

Deep sores are dressed and left out of the cast for one week to allow healing.

Casting is then resumed with special care to avoid relapse.

Cast removal

Each cast is removed in clinic just before a new cast is

applied. Cast removal is avoided before coming to clinic because

considerable correction can be lost from the time the cast is removed until

the new one is placed. Options for removal Using a cast saw is avoided because it is frightening to

the infant and family and may also cause injury to the skin.

Cast knife removal The cast is soaked in water for about 20 minutes, and

then wrapped in wet cloths before removal. This can be done by the parents

at home just before their visit. One can use a plaster knife, to avoid cutting

the skin.The above-knee portion of the cast is removed first and finally,

below-knee portion of the cast is removed .

Soaking and unwrapping This is an effective method, but requires more

time. Cast is soaked thoroughly in water and when completely soft, it is

unwrapped. To make this process easier, the end of the plaster is left free

for identification.

Common Management Errors

Pronation or eversion of the foot This position worsens the deformity by

increasing the cavus. Pronation does nothing to abduct the adducted and

inverted calcaneus, which remains locked under the talus. It also creates a

new deformity of eversion through the mid and forefoot, leading to a

beanshaped foot. “Thou shall not pronate!”

External rotation of foot to correct adduction while calcaneus remains in

varus This causes a posterior displacement of the lateral malleolus by

externally rotating the talus in the ankle mortise. This displacement is an

iatrogenic deformity.Avoid this problem by abducting the foot in flexion and

slight supination to stretch the medial tarsal ligaments, with counter-pressure

applied on the lateral aspect of the head of the talus. This allows the

calcaneus to abduct under the talus with correction of the heel varus.

Casting errors

Failure to manipulate The foot should be immobilized with the contracted

ligaments at maximum stretch obtained after each manipulation. In the

cast, the ligaments loosen, allowing more stretching at the next session.

Short-leg cast The cast must extend to the groin. Short-leg casts do not hold

the calcaneus abducted .

Premature equinus correction Attempts to correct the equinus before the

heel varus and foot supination are corrected will result in a rocker-bottom

deformity. Equinus through the subtalar joint can be corrected by calcaneal

abduction.

Failure to use appropriate night bracing Using a short leg brace is avoided

as it fails to hold the foot in abduction. The external bar brace should be

used full time for 3 months and at night for 4 years. Failure of appropriate

bracing is the most common cause of relapse.

Attempts to obtain perfect anatomical correction It is wrong to assume that

early alignment of the displaced skeletal elements will result in normal

anatomy. Long-term follow-up radiographs show abnormalities. However,

good long-term function of the clubfoot can be expected. There is no

correlation between the radiographic appearance of the foot and long-term

function.

Tenotomy

Indication for tenotomy Tenotomy is indicated to correct equinus when

cavus, adductus, and varus are fully corrected but ankle dorsiflexion remains

less than 10 degrees above neutral. It is made certain that abduction is

adequate for performing the tenotomy.

Characteristics of adequate abduction The foot is sufficiently abducted to

safely bring the foot into 0 to 5 degrees of dorsiflexion before performing

tenotomy.The best sign of sufficient abduction is the ability to palpate the

anterior process of the calcaneus as it abducts out from beneath the talus.

Abduction of approximately 60 degrees, in relationship to the frontal plane

of the tibia is possible.

Neutral or slight valgus of os calcis is present. This is determined by

palpating the posterior os calcis.

Remember that this is a three-dimensional deformity and that these

deformities are corrected together. The correction is accomplished by

abducting the foot under the head of the talus. The foot is never pronated.

Preparing the family The family is prepared by explaining the

procedure.The family is explained that tenotomy is a minor procedure

performed under local anesthetic in the outpatient clinic.

Equipment No.11 or No.15, or any other small blade, such as an ophthalmic

knife may be useful.

Skin preparation The foot is prepared thoroughly from midcalf to midfoot

with an antiseptic while the assistant holds the foot from the toes with the

fingers of one hand and the thigh with the other .

Anaesthesia A small amount of local anesthetic may be infiltrated near the

tendon. Too much of local anesthetic makes palpation of the tendon difficult

and the procedure may become more complicated.

Setup for the tenotomy With the assistant holding the foot in maximum

dorsiflexion, a site about 1.5 cm above the calcaneus is selected for

tenotomy. A small amount of local anesthetic is infiltrated just medial to the

tendon at the site selected for the tenotomy. The anatomy is kept in mind.

The neurovascular bundle is anteromedial to the heel cord. The heel-cord

tendon lies within the tendon sheath

Tenotomy The tip of the scalpel blade is inserted from the medial side,

directed immediately anterior to the tendon . The flat part of the blade is kept

parallel to the tendon. The initial entry causes a small longitudinal incision.

Care must be taken to be gentle so as not to accidentally make a large skin

incision. The tendon sheath is not divided and left intact . The blade is then

rotated, so that its sharp edge is directed posteriorly towards the tendon. The

blade is then moved a little posteriorly. A “pop” is felt as the sharp edge

releases the tendon. The tendon is not cut completely unless a “pop” is

appreciated. An additional 15 to 20 degrees of dorsiflexion is typically

gained after the tenotomy .

Post-tenotomy cast After correction of equinus by tenotomy, the fifth cast is

applied with the foot abducted 60 to 70 degrees with respect to the frontal

plane of the ankle, and 15 degrees dorsiflexion. The foot looks over-

corrected with respect to the thigh. This cast holds the foot for 3 weeks

after complete correction. It should be replaced if it softens or becomes

soiled before 3 weeks. The baby and mother may go home immediately. No

analgesic is necessary. This is usually the last cast required in the treatment

program.

Cast removal After 3 weeks, the cast is removed. Twenty degrees of

dorsiflexion is now possible. The tendon is healed. The operative scar is

minimal. The foot is ready for bracing . The foot appears to be over-

corrected into abduction. This is often a concern to the caregiver.

Errors during tenotomy

Premature equinus correction Attempts to correct the equinus before the

heel varus and foot supination are corrected will result in a rocker-bottom

deformity. Equinus through the subtalar joint can be corrected only if the

calcaneus abducts. Tenotomy is indicated after cavus, adductus, and varus

are fully corrected.

Failure to perform a complete tenotomy The sudden lengthening with a

“pop” or “snap” signals a complete tenotomy. Failure to achieve this may

indicate an incomplete tenotomy. The tenotomy maneuver is repeated to

ensure a complete tenotomy if there is no “pop” or “snap.

Bracing

Bracing is essential At the end of casting, the foot is abducted to an

exaggerated amount, which should measure 60 to 70 degrees (thigh-foot

axis).After the tenotomy, the final cast is left in place for 3 weeks. Ponseti’s

protocol then calls for a brace to maintain the foot in abduction and

dorsiflexion. This is a bar attached to straight-last open-toe shoes. This

degree of foot abduction is required to maintain the abduction of the

calcaneus and forefoot and prevent relapse. The medial soft tissues remain

stretched out only if the brace is used after the casting.

In the brace, the knees are left free, so the child can

kick them “straight” to stretch the gastrosoleus tendon. The abduction of the

feet in the brace, combined with the slight bend (convexity away from the

child), causes the feet to dorsiflex. This helps maintain the stretch on the

gastrocnemius muscle and heel-cord tendon. Ankle-foot orthoses (AFO’s)

are not useful because they only keep the foot straight with neutral

dorsiflexion.

Bracing protocol

Three weeks after the tenotomy, the cast is removed and

a brace is applied immediately. The brace consists of open-toe hightop

straight-last shoes attached to a bar . For unilateral cases, the brace is set at

60 to 70 degrees of external rotation on the clubfoot side and 30 to 40

degrees of external rotation on the normal side . In bilateral cases, it is set at

70 degrees of external rotation on each side. The bar should be of sufficient

length so that the heels of the shoes are at shoulder width .A common error

is to prescribe too short a bar, that the child finds uncomfortable. A narrow

brace is a common reason for a lack of compliance. The bar should be bent 5

to 10 degrees with the convexity away from the child, to hold the feet in

dorsiflexion.

The brace should be worn full time (day and night) for

the first 3 months after the last cast is removed. After that, the child should

wear the brace for 12 hours at night and 2 to 4 hours in the middle of the

day, for a total of 14 to 16 hours during each 24-hour period. This protocol

continues until the child is 3 to 4 years of age. Occasionally, a child will

develop excessive heel valgus and external tibial torsion while using the

brace. In such instances, the physician should reduce the external rotation of

the shoes on the bar from approximately 70 degrees to 40 degrees.

Importance of bracing The Ponseti manipulations combined with the

percutaneous tenotomy regularly achieve an excellent result. However,

without a diligent follow-up bracing program, relapse occurs in more than

80% of cases. This is in contrast to a relapse rate of only 6% in compliant

families (Morcuende et al.).

When to stop bracing How long should the nighttime bracing protocol

continue? As it is often difficult to determine severity, we recommend that

all feet should be braced for to 3 to 4 years. Most children get used to the

bracing, and it becomes part of their lifestyle. If after 3 years of age

compliance becomes a problem, it may become necessary to discontinue the

bracing. The child is closely followed for evidence of relapse. Should early

relapse be observed, bracing should be promptly started again.

Types of braces Modifications of the original Ponseti brace provide some

advantages. To prevent the foot from sliding out of the shoe, a pad may be

placed in the counter of the shoe. New designs make the foot more secure in

the brace, more easily applied to the infant, and allow the infant to move.

This flexibility may improve compliance. Several of the brace options are

shown.

John Mitchell has designed a brace under Dr. Ponseti’s direction. This

brace consists of shoes made of a very soft leather and a plastic sole that is

molded to the shape of the child’s foot, making this shoe very comfortable

and easy to use.

Dr. Matthew Dobbs of the Washington University School of Medicine in

St. Louis, USA developed a new dynamic brace for clubfoot that allows the

foot to move while maintaining the required rotation of the foot. An ankle-

foot orthoses are required as part of this brace to prevent ankle plantar

flexion.

M.J. Markel developed a brace that allows the parent to first place the shoes

on the infant and then “click” each shoe onto the bar .

Dr. Jeffrey Kessler of the Kaiser Hospital in Los Angeles, USA developed

a brace that is flexible and inexpensive. The bar is made of 1/8” thick

polypropylene. The brace may improve compliance because it is well

accepted by the infant.

Increasing Brace Compliance The most compliant families are those who

understand Ponseti management and the importance of bracing.

Continued education Every opportunity is taken to educate the family about

Ponseti management.

Written material is very helpful when available. Often published material is

more convincing than information given verbally .

During weekly casting questions from the parents or other family members

are answered. Failures are most likely due to premature discontinuation of

bracing. This phase of management is repeatedly emphasized. The families

should be aware that maintaining the correction with bracing is equally

important to gaining the correction by casting and tenotomy.

Instructions for bracing

Assigning responsibility Once correction has been achieved, the

responsibility is clearly passed on to the family to maintain the correction

with bracing. Assigning that responsibility to the father may be appropriate

in some situations.

Demonstrate families’ ability to apply the brace Demonstrate how to apply

the brace. Remove the brace and ask the parent to apply the brace while

being supervised. Make certain the infant is comfortable in the brace. If the

infant is uncomfortable, remove the brace and examine the skin for evidence

of irritation with reddening of the skin .

Preparing the infant For the first few days, the brace may be removed for

brief periods to improve tolerance. The parents are adviced to avoid

removing the brace if the infant cries. If the infant learns that by crying the

brace will be removed, the pattern will be difficult to correct. The family is

encouraged to make the bracing a part of the normal life of the infant .

Follow-up

A return visit is scheduled in 10–14 days to monitor the use of the brace. If

the bracing is going well, the next visit will be in about 3 months. At that

time, the bracing may be discontinued during the day. The brace must be

applied for naps during the day and sleep during the night.

Relapses

Recognizing relapses Once the cast is removed and the bracing is started,

plan to see the child back at the following schedule to check for compliance

and for evidence of relapse:

At 2 weeks to check for compliance of full-time bracing.

At 3 months to graduate to the nights-and-naps schedule.

Until age 3 check every 4 months to monitor compliance and for relapses.

Age 3 to 4 years check every 6 months.

From 4 years until maturity check every 1 to 2 years.

Early relapses The infant shows loss of foot abduction and/or of

dorsiflexion correction with recurrence of adductus and cavus.

Relapses in toddlers Check for evidence of deformity both by examining the

foot with the infant on the mother’s lap, and while walking. As the child

walks toward the examiner, look for supination of the forefoot. Supination

is due to the tibialis anterior muscle overpowering the weaker peroneals . As

the child walks away from the examiner, look for heel varus . The seated

child should be examined for ankle range of motion and loss of passive

dorsiflexion. Check the range of motion of the subtalar and midtarsal joints.

These joints should move freely. A loss of free mobility is evidence of

relapse.

Reasons for relapses

The most common cause of relapse is noncompliance of

the bracing program. Morcuende found that relapses occur in only 6% of

compliant families and in more than 80% of noncompliant families. If relapse

occurs in infants who are braced, the cause is an underlying muscle

imbalance of the foot that can lead to stiffness and relapse.

Casting for relapses

At the first sign of relapse, apply one to three casts to

stretch the foot out and regain correction. This cast management is the same

as the original Ponseti casting program. Once the deformity is corrected by

casting, start the bracing program again. Even in the child with a severe

recurrence, sometimes casting is very effective.

Equinus relapse

Recurrent equinus is a deformity that can complicate

management. The tibia seems to grow faster then the gastrosoleus tendon

unit. The muscle is atrophic and the tendon appears long and fibrotic.

Continue weekly casting until the foot can be brought to about 10˚ of

dorsiflexion. If this is not achieved in 4–5 casts in children under 4 years of

age repeat the percutaneous heel-cord tenotomy. Once the equinus is

corrected, the nighttime bracing program is resumed.

Varus relapse

Varus heel relapses are more common than equinus relapses.

They can be seen with the child standing and should be treated by re-casting

in the child between age 12 and 24 months, followed by resuming of a strict

bracing program.

Dynamic supination

Some children, usually between ages 3 and 4 years, with

only a dynamic supination deformity will benefit from an anterior tibialis

tendon transfer. This transfer is only effective if the deformity is dynamic

and not fixed. The procedure is delayed until after 30 months of age when

the lateral cuneiform becomes ossified. Normally, bracing is not required

after the transfer.

Anterior Tibialis Tendon Transfer

Indication

Transfer is indicated if the child is more than 30 months of age

and has a second relapse. Indications include persistent heel varus and

forefoot supination during walking; the sole shows thickening of the lateral

plantar skin.

The deformity is corrected It is made certain that all fixed deformities are

corrected by two or three casts before performing the transfer. Usually

cavus, adductus, and varus are corrected. Equinus may be resistant. If the

foot easily dorsiflexes to 10 degrees, only transfer is needed. Otherwise a

tenotomy of the heelcord is needed.

Anaesthesia, positioning and incisions The patient is put under general

anesthetic and positioned supine. A high-thigh tourniquet is used.A

dorsilateral incision is made centered on the lateral cuneiform. Its surface

marking is a proximal projection of third metatarsal in front of the head of

the talus . The dorsomedial incision is made over the insertion of the anterior

tibialis tendon.

Anterior tibialis tendon is exposed and detached at its insertion. Extending

the dissection too far distally is avoided to avoid injury to the growth plate

of the first metatarsal.

Anchoring sutures are placed with multiple passes through the tendon to

obtain secure fixation.

The tendon is transferred subcutaneously to the dorsolateral incision . The

tendon remains under the retinaculum and the extensor tendons.

Subcutaneous tissue is freed to allow the tendon a direct course laterally.

Lateral cuneiform is located using an X-ray.Site for transfer is identified

and a drill hole (3.8–4.2) is made in the middle of the lateral cuneiform large

enough to accommodate the tendon.

Sutures are thread through a straight needle on each of the securing

sutures. One needle is passed into the hole. The first needle in the hole is left

while passing the second needle to avoid piercing the first suture.

A heel-cord tenotomy is performed if required.

Two needles are placed through a felt pad and then through different holes

in the button to secure the tendon. Tendon is secured with the foot held in

dorsiflexion and the tendon is pulled into the drill hole by traction on the

fixation sutures and the fixation suture tied with multiple knots.

Supplemental fixation done by suturing the tendon to the periosteum at the

site where the tendon enters the cuneiform, using a heavy absorbable suture .

In neutral position without support , the foot should rest in neutral plantar

flexion and neutral valgus-varus. Cast immobilization in a long-leg cast is

applied with the foot abducted and dorsiflexed.

Postoperative care Usually, the patient remains hospitalized overnight. The

sutures absorb. The cast is removed at 6 weeks. The child may mobilize

weight-bearing as tolerated. No bracing is necessary after the procedure.

The child is again seen in 6 months to assess the effect of the transfer.

PART II

Aim of the Study

The aims of the study are

1. To analyse the efficacy of Ponseti method of serial manipulation

and casting in the management of Congenital Idiopathic

Clubfoot.

2. To evaluate the efficacy of Ponseti method in reducing the need for

corrective surgeries and its complications.

3. To compare the educational status of the parents and their

compliance in bracing and follow up.

4. To analyse the usefulness of Ponseti method in Idiopathic

Clubfoot in a developing country like India.

Materials & Methods

The study was carried out in patients having

classical idiopathic clubfeet who were less than 5 months of age (5 to 90 days)

attending the clubfoot clinic in the Department of Orthopaedics ,Coimbatore

Medical College Hospital ,Coimbatore , Tamilnadu , India. Thirty two children (47

feet) were treated by the Ponseti method between June 2007 to June 2009 and

followed for a period of 6mo to one year.

The cases were referred to us from paediatric wards,

paediatric surgery wards and obstretics wards. Four babies manipulated and given

serial casting & declared failure elsewhere, were referred for treatment. All the

patients were treated on an outpatient programme. An informed consent was taken

from the parents regarding management, complications & compliance. Older

patients or those having non-idiopathic deformities were excluded from the study

Every clubfoot under Ponseti management was “scored” each week for HS (hind-

foot score), MS (mid-foot score), and G (total score). Manipulation and casting

were carried out without any anaesthesia or sedation.

The general principles of the Ponseti method for

manipulative correction were followed : correcting all components simultaneously,

starting from pronation and leaving equinus for the last.Weekly manipulation &

below-knee casts were given & extended to above-knee casts with knee in 90

degrees of flexion.These were applied for four weeks and further, as per correction

achieved. Tenotomy was done when HS>1, MS<1 and after the head of the talus is

covered. Before performing tenotomy, it was assured that the foot is sufficiently

abducted. This was done in the operation theatre as a short day-care procedure and

the patients were discharged on the same day. Just before tenotomy, the brace

measurements were taken so that by the time the patient was to be fitted with the

brace it would be ready.Completion of cast treatment was determined by three

factors viz 1.when after the last cast at least 30° of passive dorsiflexion was

possible, 2.the foot was well corrected, and 3.the tenotomy scar was minimal.

A Dennis Brown brace was applied immediately after

the last cast is removed, three weeks after tenotomy. For unilateral cases, the brace

was set at 70° of external rotation on the clubfoot side, and 40° on the normal side.

In bilateral cases, it was set at 70° of external rotation on each side. The bar should

be of sufficient length so that the heels of the shoes are at shoulder width. The bar

should be bent 5–10° with the convexity away from the child, to hold the feet in

dorsiflexion. The brace should be worn full-time , day and night, for the first three

months after the tenotomy cast is removed, then the brace should be worn for 12

hours at night and two to four hours in the middle of the day, for a total of 14–16

hours ie.,nights and naps protocol, during each 24-hour period. After applying the

brace for the first time after the tenotomy cast was removed, the child returns

according to the following schedule.

– Two weeks ….to check for compliance issues

– Three months .…to teach the nights-and-naps protocol

– Every four months until age three years ….to monitor compliance

and check for relapses

– Every six months until age 4 years

– Every one to two years until skeletal maturity

At walking age, the babies wore specially designed

straight last high-top lace-up shoes during daytime. Bracing & shoes were to be

continued for up to four years of age.

During follow-up, the relapses, if any, were treated

appropriately. Equinus required repeat tenotomy, while forefoot adduction, cavus

and intoeing were all treated with repeat casting. Special clubfoot clinics were

organised, where patients on splints were called and used to share their experience

with the new patients in casts. We maintained a good photographic record of all the

patients and showed these to the new patients, which assured them about this

relatively new method for them.

Achieving no correction by 9 months was considered a

failure, after which surgery was planned with the parents’ consent. No infections,

skin necrosis, neurovascular compromise, or profuse bleeding were observed

following tenotomy.

(47%)]

assessed

for a pe

unilater

first-bor

our stud

dysplas

weeks.

in 32 chi

d in the pr

eriod of six

ral on righ

rn children

dies was U

ia of hip (t

The tota

8

9

13%

Ob

A

ldren were

resent serie

x to twelve

F

ht side and

n. Forty on

T

Umblical h

two cases).

al mean s

15

87%

bservat

A total of

e treated b

es, carried

e months.

Fifteen chi

d eight we

ne feet (87%

The most

hernia (fou

. Internal ti

Twenty e

score at p

BILATER

LEFT

RIGHT

FIRST BORN

OTHER

tions &

f 47 feet [

by the Pon

d out from

ildren had

ere left sid

%) were of

common

ur cases). N

ibial torsio

eight case

presentatio

AL

4

& Res

[17 males

nseti meth

June 2007

d bilateral

ded. Forty

f children b

associated

Next comm

on was seen

es (87.5%

on was 3.

47%

4

2

sults

(53%) an

hod and th

7 to June

l clubfeet

one feet (

born full-te

d congenit

mon was D

n in one of

) presente

.79. The

53%

D

UH

nd 15 fem

he results w

2009 follo

, nine w

(87%) wer

erm.

al anomal

Developme

f the cases.

ed within

correspon

MALES

FEMALES

DDH

Umb Hernia

males

were

owed

were

re of

ly in

ental

.

six

nding

HS(hind

majority

mean of

weeks.

scores o

follow-u

Equinus

casting.

dfoot)score

y of cases

f 5.3.

Tenotomy

of more tha

up. Of thes

s required

Correctio

e and MS

(84%) req

Pirani Scoat   6 m

            0 

           0.5 

  1.0 

         >2.0 

y was requ

an 3. The a

se four wer

d repeat te

on withou

0

10

20

30

T

(midfoot)s

quired less

ore    o 

Numb

           

The avera

uired in 28

average dur

Ten

re forefoot

enotomy, w

t surgery

PERCUTANEOTENOTOMY OF

28

score were

s than six c

 

ber of Cases 

21 

4 

3 

    4 

age durati

cases (87

ration of fo

cases of r

t adduction

while the

was obtai

US F TA

NOT DO

4

e 1.96 and

casts to com

 

Percentag

65.6%

12.5%

9.3% 

          12.5%

ion of ca

.5%) and m

follow-up w

relapses w

n, five wer

rest were

ined in tw

ONE

4

d 1.83 resp

mplete cor

ge 

% 

ast applica

most of th

was 9 mont

were encou

e equinus

all treate

wenty eigh

pectively.

rrection, w

ation was

hese had P

ths .

untered du

and one ca

ed with re

ht cases. F

The

with a

5.3

irani

uring

avus.

epeat

Four

(12.5%) patients were considered failure after treatment by the Ponseti method &

required corrective Posteromedial soft tissue release. Following surgery, all the

four patients had Pirani score of less than 1.0. No postoperative wound infection

was noted.

RELAPSES

5

4

1

0

1

2

3

4

5

6

EQUINUS FOREFOOT ADDUCTION

CAVUS

Discussion

Clubfoot or congenital talipes equinovarus is a

complex deformity of foot that requires meticulous and dedicated efforts on the

part of the treating physician and parents for the correction of the deformity. In

general, the treatment needs to be started as soon as possible and should be

followed under close supervision. Our study demonstrates the effective use of

manpower, integration with other programs and guided motivation to identify the

cases and correction of the deformity in all the cases (87.5%) without surgical

intervention.

The order of birth seemed to have an influence

on the occurrence of clubfoot, with 87.5% of cases in the first-born child, which is

in accordance with various other studies. There was no relationship of clubfoot to

the type of birth.

Of the children with clubfoot presented to us,

87.5% were within six weeks of birth, because of good inter-departmental co-

ordination . We conducted special clubfoot clinics for new patients, where our old

patients on night splints were made to interact with the new patient’s parents and

87%

13%

PONSETI FULL CORRECTION

SURGERY

assure them about the treatment and compliance. Results were better if this method

of treatment was started as early as possible after birth.

The earliest cast applied was at an age of one day. The

maximum age at which a cast was applied was at five months.

The average duration of cast application was 5.3

weeks. Those feet which required a greater number of casts in our study had a

Pirani score of 6 at the onset of treatment. The duration of casts for more than 85%

of feet was five weeks or less .The duration decreased over time as we mastered

the technique and started getting earlier correction.Ponseti et al. reported 5–12

weeks’ duration of casts (average, 9.5 weeks). In another study by Laaveg etal., the

average duration was 8.6 weeks. Morcuende reported that 90% of the patients

required five or fewer casts.

In our study, tenotomy was needed in 87.5% of the

cases and these patients had initial Pirani score > 3.5. It shows that tenotomy was

required in those patients who initially have severe deformity. Tenotomy was done

when there is equinus deformity, after achieving full forefoot abduction. Pirani

10 11

6

23

02468

1012

4 5 6 7 8

Num

ber o

f Cases

Number of Casts for full correction

carried out tenotomy in over 90% of his clubfoot patients. Laaveg et al. did

tenotomy in 78% cases. In the study by Dobbs et al., tenotomy was required in

91% cases.We did not come across any complication following tenotomy.

We included those patients with follow-up of more than

6 months. Ponseti had a series with a long follow-up. The results for the current

series have been very encouraging. The results of our series are comparable with

other studies.

The most common relapse seen was forefoot adduction

(four cases); this was due to non-compliance of the brace and also partly due to

application of the brace incorrectly at home. Since most of the patients in the

current study are from the lower class , educational level is low and thus they fail

to understand the importance of the proper way to reapply the brace to maintain

correction.

Strict instructions for the brace application,

motivation, peer comparison and more frequent follow-up have led to increased

compliance of the brace for these patients and early detection of any relapse.

Morcuende et al.reported a 6% relapse rate in compliant patients and 80% in non-

compliant patients. The underlying cause for the relapse in the compliant group

was underlying muscle imbalance of the foot and ligament stiffness.

We encountered five cases of equinus relapse, which

was due to brace removal by patient. This was corrected by repeat percutaneous

tenotomy and application of corrective casts for three weeks. Cavus and forefoot

adduction was encountered initially due to non-compliance of the brace but later

on with regular follow-up and strict brace compliance these relapses were

encountered less often. In the study by Morcuende et al., who used the accelerated

Ponseti protocol for clubfoot on 230 patients (319clubfeet), 36 had relapses

(11.65%). Ponseti et al.reported a high incidence of relapse in their earlier

studies(56%). In another study by Laaveg et al., relapse was seen in 47% (49

clubfeet).

The feet of patients compliant with the brace use

remained better corrected than the feet of those patients who were not compliant.

We used a Dennis Brown foot abduction brace in our study. After six months of

treatment (at the time when patients were on night splints) the Pirani score had

become zero for most of the patients , indicating successful correction of the

clubfoot deformity.

Ponseti method of conservative clubfoot treatment is

an excellent method of club foot treatment, of which there have been successful

results in western countries .The follow-up of patients treated with this deformity

has been over 40 years in some of these studies and these persons are leading a

normal life now.

Ponseti method avoids the complications of surgery

and gives a painless, mobile,normal-looking, functional foot which requires no

special shoes and allows fairly good mobility. Results of the clubfoot treatment by

Ponseti technique in our study have been good and rewarding and now all the

clubfeet are treated in our institution by this technique only. Our study shows that

managing a good referral by proper education and motivation, along with

integration into other departments, improves the outcome not only in terms of age

at presentation but also for deformity correction. Proper motivation and persuading

the parents to accept long-term brace treatment helps maintain the correction over

a longer period of time and prevents relapse.

Conclusion

The Ponseti method is a very safe, efficient

treatment for the correction of Idiopathic Clubfoot that decreases the need for

extensive corrective surgery and its complications. Following the principles and

technical details of Ponseti method will assure optimal results in almost all

patients.

                                                                                    Babies presenting early have an excellent chance

of achieving full correction with fewer casts with or without percutanoeus

tenotomy of tendoachilles. Babies of parents, who are better educated have more

compliance in following instructions regarding splint and shoes application and

follow up.

In a developing country like India, where there

is dearth of proper operative facilities in remote areas, Ponseti technique is an

easy, safe, result-oriented and economical method of Clubfoot management.

 

 

 

Bibliography

1. 1963 Ponseti IV, Smoley EN. Congenital clubfoot: the results of treatment. J

Bone Joint Surg Am 45(2):2261¬–2270.

2. 1966 Ponseti IV, Becker JR. Congenital metatarsus adductus: the results of

treatment. J Bone Joint Surg Am 43(4):702–711.

3. 1972 Campos J, Ponseti IV. Observations on pathogenesis and treatment of

congenital clubfoot. Clin Orthop Relat Res 84:50–60.

4. 1974 Ionasescu V, Maynard JA, Ponseti IV, Zellweger H. The role of collagen

in the pathogenesis of idiopathic clubfoot: biochemical and electron microscopic

correlations. Helv Paediatr Acta 29(4):305–314.

5. 1980 Ippolito E, Ponseti IV. Congenital clubfoot in the human fetus: a

histological study. J Bone Joint Surg Am 62(1):8–22.

6. 1980 Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital

clubfoot. J Bone Joint Surg Am 62(1):23–31.

7. 1981 Brand RA, Laaveg SJ, Crowninshield RD, Ponseti IV. The center of

pressure path in treated clubfoot. Clin Orthop Relat Res 160:43–47.

8. 1981 Ponseti IV, El-Khoury GY, Ippolito E, Weinstein SL. A radiographic

study of skeletal deformities in treated clubfoot. Clin Orthop Relat Res 160:30–42.

9. 1992 Ponseti IV. Treatment of congenital clubfoot. [Review, 72 refs] J Bone

Joint Surg Am 74(3):448–454.

10. 1994 Ponseti IV. The treatment of congenital clubfoot. [Editorial] J Orthop

Sports Phys Ther 20(1):1.

11. 1995 Cooper DM, Dietz FR. Treatment of idiopathic clubfoot: a thirty-year

follow-up note. J Bone Joint Surg Am 77(10):1477–1489.

12. 1996 Ponseti IV. Congenital Clubfoot: Fundamentals of Treatment. Oxford

University Press.

13. 1997 Ponseti IV. Common errors in the treatment of congenital clubfoot. Int

Orthop 21(2):137–141.

14. 1998 Ponseti IV. Correction of the talar neck angle in congenital clubfoot with

sequential manipulation and casting. Iowa Orthop J18:74–75.

15. 2000 Ponseti IV. Clubfoot management. [Editorial] J Pediatr Orthop

20(6):699–700.

16. 2001 Pirani S, Zeznik L, Hodges D. Magnetic resonance imaging study of the

congenital clubfoot treated with the Ponseti method. J Pediatr Orthop 21(6):719–

726.

17 .2003 Ippolito E, Farsetti P, Caterini R, Tudisco C. Long-term comparative

results in patients with congenital clubfoot treated with two different protocols. J

Bone Joint Surg Am 85(7):1286–1294.

18. 2003 Morcuende JA, Egbert M, Ponseti IV. The effect of the internet in the

greatment of congenital idiopathic clubfoot. Iowa Orthop J 23:83–86.

19. 2004 Morcuende JA, Dolan L, Dietz F, Ponseti IV. Radical reduction in the

rate of extensive corrective surgery for clubfoot using the Ponseti method.

Pediatrics 113:376–380.

20. 2004 Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA.

Factors predictive of outcome after use of the Ponseti method for the treatment of

idiopathic clubfeet. J Bone Joint Surg Am 86(1):22–27.

21. 2005 Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an

accelerated Ponseti protocol for clubfoot. J Pediatr Orthop 25(5):623–626.

22. 2005 Konde-Lule J, Gitta S, McElroy T and the Uganda Sustainable Clubfoot

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Rajat Agrawal Agrawal Orthopaedic Hospital, Gorakhpur, India :Treatment of

congenital club foot with Ponseti method.

24. 2006 Dobbs MB, Nunley R, Schoenecker PL. Long-term follow-up of patients

with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg Am

88:986–996.

25. 2007 McElroy T, Konde-Lule J, Neema S, Gitta S; Uganda Sustainable

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26. 2007 Lourenço AF, Morcuende JA. Correction of neglected idiopathic club

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ANNEXURES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLINICAL PHOTOGRAPHS

                                                                 CASE  I  ‐  BILATERAL    CTEV 

                                                                

                AT  PRESENTATION                                                                             

                                                               

                  PRE    TENOTOMY 

                                                               

                POST  TENOTOMY                                                                            FULL   CORRECTION 

                                                                   

                                                                      DENNIS   BROWN  SPLINT                                         

                                                               CASE  II  ‐  BILATERAL    CTEV 

                                                          

              AT    PRESENTATION                                                                                

   

                                                             

             PRE   TENOTOMY                                                                                    POST   TENOTOMY 

 

                                                          

               FULL   CORRECTION                                                                                   DB   SPLINT                         

                                                              

                                                              

                                                               CASE   III  ‐ BILATERAL     CTEV 

                                                                            

                   AT   PRESENTATION 

                                                                        

                   PRE  TENOTOMY                                                                                  POST   TENOTOMY 

                                                                           

                  FULL   CORRECTION 

                                                                      

                                                                                 DB  SPLINT 

                                                                  CASE   IV  ‐    LEFT  CTEV 

                                                                 

        AT      PRESENTATION                                                                                   

                                                                        

                PRE   TENOTOMY                                                                                 POST    TENOTOMY 

                                                                        

                        

                                                                         

            FULL   CORRECTION                                                                                         DB  SPLINT 

                                                                     CASE  V  ‐ LEFT   CTEV 

                                                                    

              AT   PRESENTATION 

                                   

             PRE   TENOTOMY                                                                                 POST    TENOTOMY                                                          

                                                                          

                                                                    FULL    CORRECTION 

                                                               

                                                                             DB    SPLINT 

                                                                         CASE  VI  ‐ LEFT   CTEV 

                                              

               AT  PRESENTATION 

                                                      

            PRE   TENOTOMY                                                                                      POST   TENOTOMY      

                                                                            

FULL   CORRECTION                                                                                           

                                                                                    

                                                                             DB    SPLINT 

                                                                    CASE  VII ‐  RIGHT    CTEV 

                                                  

           AT   PRESENTATION 

                             

             PRE   TENOTOMY                                                                                 POST   TENOTOMY 

                      

              FULL    CORRECTION 

                                                                   

                                                                            DB    SPLINT                                               

                                                                CASE  VIII  ‐ RIGHT   CTEV 

                                                            

             AT  PRESENTATION 

                                                            

           PRE   TENOTOMY                                                                POST   TENOTOMY 

                            

                                  

            FULL    CORRECTION 

                                                                 

                                                                           DB    SPLINT 

                                                                  CASE  IX  ‐  RIGHT   CTEV 

                                             

          AT   PRESENTATION 

                                                                                 

         PRE   TENOTOMY                                                          POST  TENOTOMY 

                                   

                                                                                                                              FULL   CORRECTION   

                                                                                    

               DB   SPLINT                                        CTEV  BOOTS 

 

 

                                                         CASE  X ‐   BILATERAL  CTEV – FAILURE 

 

                    

            AT  PRESENTATION,  3 MO 

 

                                                         

              AFTER  7  CASTS                            

 

                       

                                                                    BEFORE     SURGERY 

                                                                    

                                                                         

                                                                  CASE  X ‐  CONTINUED 

 

                                     

                                                                      AFTER       SURGERY 

 

                       

                                                                            DB    SPLINT 

 

 

 

 

                                                           

                                                               CASE  XI  ‐  LEFT  CTEV  ‐  FAILURE 

                                                    

                 AT PRESENTATION,5MO 

                                                                               

                                                          AFTER  8 CASTS 

                                                            

                  BEFORE    SURGERY                                                                             AFTER    SURGERY 

                                                                                                                                   FULL  CORRECTION                                DB  SPLINT 

I  

 S. No 

 Name of Baby/Sex 

 Deli‐ very 

 Age at First  Cast  

Assoc‐ Iated 

 Dis 

Parents  

Educ‐ ation 

 Laterality 

Pirani Score 

Total No Of 

Casts 

 Percuta‐ neous 

 Tenot‐ omy 

DB/ CTEV 

 Shoes 

 Compl‐iance 

 

OutcomePirani Score At 6mo 

 Relapse 

 PMR 

MidFoot 

HindFoot 

 1 

 B/O 

Mariammal FEMALE 

 FTND 

 2 

Days  

 ‐ 

 X Std 

 Bilat‐eral 

 1.5 

 1.5 

 4 

   

 

 Good 

 0 

 ‐  

 ‐ 

 2 

B/O Komalavalli 

MALE 

LSCS Pre‐term 

 4 

Wks 

 ‐

 XII Std 

 Right 

 1.5 

 2 

 5 

   

 

 Good 

 

 0 

 ‐ 

 ‐ 

 3 

B/O Vasanthi FEMALE 

 FTND 

 5 

Days 

 ‐ 

 X Std 

 Right 

 1.5 

 1.5 

 4 

   

 

 Good 

 0 

 ‐ 

 ‐ 

 4 

B/O Amutha MALE 

LSCS Full Term 

 1 

Day 

 DDH 

 X Std 

 

 Left 

 2 

 2.5  

 6 

 ‐‐‐ 

 

 Good 

 0.5 

equinus 

PC‐Teno‐tomy done 

 ‐ 

 5 

B/O Valliammai FEMALE 

 FTND 

 3 

Wks 

 ‐ 

 XII Std 

 Right 

 1.5 

 1.5 

 7 

   

 

 Good 

 0 

 ‐ 

 ‐ 

 6 

B/O Tamilarasi MALE 

 FT 

Breech 

 2 

Wks 

 ‐ 

 X Std 

 Bilateral 

 2 

 2 

 4 

   

 

 Good 

0.5 Forefoot adduction 

POP Correc‐tion 

 ‐ 

 7 

B/O Jeyamma MALE 

LSCS Full Term 

 

 10 Days 

 Umb hernia 

 BSc 

 Right 

 2.5 

 1.5 

 5 

   

 

 Good 

 ‐ 

 ‐ 

 ‐ 

 8 

B/O Meenakshi FEMALE 

 FTND 

 4 

days 

 ‐ 

 XII Std 

 Left 

 1.5 

 1.5 

 4 

 ‐‐‐ 

 

 

 Good 

 ‐ 

 ‐ 

 ‐ 

II  

 S. No 

 Name of Baby/Sex 

 Deli‐ very 

 Age at First  Cast  

Associ‐Ated  

Dis 

Parents  

Educ‐ Ation 

 Later‐ ality 

Pirani Score 

Total No Of 

Casts 

 Percuta‐ neous 

 Tenot‐ omy 

DB/ CTEV 

 Shoes 

 Compli‐ance 

 

OutcomePirani Score A t 6mo 

 Relapse 

 PMR 

MidFoot 

HindFoot 

 9 

B/O Thangam FEMALE 

 FTND 

 3 

Days 

 Umb hernia 

 X Std 

 Left 

 2 

 2.5 

 4 

 ‐‐‐ 

 

 Good 

 0.5 

equinus 

PC‐Teno‐tomy done 

 ‐ 

 10 

 Krithik MALE 

LSCS Pre‐ Term 

 

 3 Mo 

 ‐ 

Un educa‐ted 

 Bilateral 

 2.5 

 3.5 

 7 

   

 

 Bad 

 3.5  

 ‐  

 

 11 

B/O Radha FEMALE 

 FTND 

 2 

Wks 

 ‐ 

 B Com 

 Right 

 1.5 

 2 

 5 

   

 

 Good 

1.0 Equinus, Forefoot adduction 

PC‐Teno ‐tomy & POP 

 ‐ 

 12 

B/O Sundari MALE 

LSCS Full Term 

 2 

Wks 

 ‐ 

Un Educa‐ted 

 Right 

 2 

 2.5 

 6 

   

 

 

 Good 

 ‐  

 ‐ 

 ‐ 

 13 

B/O Saraswathi FEMALE 

 FT 

Breech 

 5 

Wks 

 ‐ 

 X Std 

 Left 

 1.5 

 2.5 

 6 

   

 

 Good 

 ‐ 

 ‐ 

 ‐ 

 14 

B/O Arulselvi MALE 

 FTND 

 2 

Days 

 ‐ 

 VI Std 

 Left 

 1.5 

 3 

 5 

   

 

 Good 

 ‐ 

 ‐ 

 ‐ 

 15 

B/O Gowri MALE 

 FTND 

 2 

Wks 

 Umb hernia 

 V Std 

 Bilateral 

 1.5 

 1.5 

 6 

   

 

 Good 

 ‐ 

 ‐ 

 ‐ 

 16 

B/O Roseline FEMALE 

 FTND 

 

 5 Mo 

 ‐ 

 X Std 

 Left 

 2.5 

 2.5 

 8 

   

 

 Good 

 3.5 

 ‐ 

 

III  

 S. No 

 Name of Baby/Sex 

 Deli‐ very 

 Age at First  Cast  

Associ‐ated  

Dis 

Parents  

Educ‐ ation 

 Later‐ality 

Pirani Score 

Total No Of  

Casts 

 Percuta‐ neous 

 Tenot‐ omy 

DB/ CTEV 

 Shoes 

 Compl‐iance 

 

OutcomePirani Score At 6mo 

 Relapse 

 PMR 

MidFoot 

HindFoot 

 17 

B/O Vasantha FEMALE 

LSCS Full Term 

 

 1 Wk 

 ‐ 

 XII Std 

 Right 

 1.5 

 2.5 

 5 

   

 

 Good 

 ‐ 

 ‐ 

 ‐ 

 18 

B/O Savithri MALE 

LSCS Full Term 

 9 

Days 

 ‐ 

 V Std 

 Left 

 1.5 

 1.5 

 4 

   

 

 

 Bad 

 ‐ 

 ‐ 

 ‐ 

 19 

B/O Anbuselvi FEMALE 

 FT 

Breech 

 12 Days 

 ‐ 

 VII Std 

 

 Left 

 2.5 

 1.5 

 4 

   

 

 Bad 

 3.0 

 ‐ 

 

 20 

B/O Thilaga FEMALE 

 Pre Term 

 15 Days 

 ‐ 

Un Educa‐ted  

 Bilateral 

 1.5 

 1.5 

 5  

   

 

 Good 

 0.5 

Cavus 

 POP 

Correc ‐tion 

 ‐  

 21 

 Paramesh MALE 

 FTND 

 4 Mo 

 ‐ 

 VIII Std 

 Bilateral 

 2 

 1.5 

 8 

   

 

 Good 

1.0 Equinus, Forefoot adduction 

PC‐Teno ‐tomy & POP 

 ‐ 

 22 

B/O Sahaymary 

MALE 

 Pre Term 

 2 

Wks 

 ‐ 

 IX Std 

 Right 

 2.5 

 1.5 

 4 

   

 

 Good 

 ‐ 

 ‐ 

 ‐ 

 23 

B/O Jeyarani MALE 

 FTND 

 12 Days 

 DDH 

 XII Std 

 Bilateral 

 3.5 

 2.5 

 5 

   

 

 

 Bad 

 2.5 

 ‐ 

 

 

 24 

B/O Nirmala FEMALE 

LSCS Full Term 

 

 5 

Days 

 ‐ 

 X  Std 

 Bilateral 

 1.5 

 2.5 

 5 

   

 

 Good 

 ‐ 

 ‐  

 ‐ 

IV  

 S. No 

 Name of Baby/Sex 

 Deli‐ very 

 Age at First  Cast  

Associ‐Ated  

Dis 

Parents  

Educ‐ ation 

 Laterality 

Pirani Score 

Total No Of 

Casts 

 Percuta‐ neous 

 Tenot ‐omy 

DB/ CTEV 

 Shoes 

 Compl‐iance 

 

OutcomePirani Score At 6mo 

 Relapse 

 PMR 

MidFoot 

HindFoot 

 25 

B/O Jesce 

FEMALE 

 FTND 

 4 

Wks 

 ‐ 

 VI  Std 

 Bilateral 

 2.5 

 1.5 

 4 

   

 

 Good 

 ‐ 

 ‐ 

 ‐ 

 26 

B/O Selvi MALE 

 FTND 

 3 

Wks 

 ‐ 

 IX  Std 

 Bilateral 

 2 

 1.5 

 5 

   

 

 

 Good 

 ‐ 

 ‐ 

 ‐ 

 27 

 Malar FEMALE 

 LSCS Full Term 

 

 4 Mo 

 Umb hernia 

 X  Std 

 Bilateral 

 1.5 

 2 

 8 

   

 Good 

1.0 Equinus, Forefoot adduction 

PC‐Teno ‐tomy & POP 

 ‐ 

 28 

B/O Indrani MALE 

 FTND 

 10 Days 

 ‐ 

 XII  Std 

 Bilateral 

 2 

 2.5 

 6 

   

 

 Good 

 ‐ 

 ‐ 

 ‐ 

 29 

B/O Anandhi MALE 

 FTND 

 2 

Wks 

 ‐ 

 X  Std 

 Bilateral 

 1.5 

 1.5 

 5 

   

 

 

 Good 

 ‐ 

 ‐ 

 ‐ 

 30 

B/O Kavitha MALE 

 FTND 

 15 Days 

 ‐ 

 XII  Std 

 Bilateral 

 1.5 

 2.5 

 4 

   

 

 Bad 

 ‐ 

 ‐ 

 ‐ 

 31 

B/O Jothi MALE 

 FTND 

 2 

Days 

 ‐ 

 X  Std 

 Bilateral 

 2 

 2.5 

 6 

 ‐‐‐ 

 

 Good 

 ‐ 

 ‐ 

 ‐ 

 32 

B/O kamalaveni 

MALE 

 FTND 

 2 

days 

 ‐ 

 X  Std 

 Right 

 2 

 2 

 5 

   

 

 Good 

 ‐ 

 ‐ 

 ‐